a. Diversion of funds from service provision to profit
Samuel argues that corporations will not divert funds from care to profit and will not squeeze out less profitable patients. There is now plenty of evidence to indicate that this is exactly what many corporations in the marketplace actually do.
The government has recently closed a web site which disputed the holocaust - an ideological position. Samuel considers the idea that health can cannot be provided in the marketplace is ideologically based. Those who have been denied care under managed care or who have been overserviced and retained against their wills in psychiatric hospitals would feel as strongly about Samuel's claim as the Jews feel about the web site. This is a case of the pot calling the kettle black! A patient who was imprisoned in a Tenet/NME psychiatric hospital in the USA as a child recently contacted me. She is still seeking redress.
Samuel claims buying a house can be equated with buying health services - Macmedicines. This is argued elsewhere on this site.
Samuel argues a variety of macroeconomic benefits f for for profit care. To a simpleton the public is paying some money for providing equitable care, regardless of the method. That money is being expended in salaries and consumables to provide care, whether publicly run, not for profit or for profit. The economic benefits and the employment should be identical. The prime practical difference is that money would be diverted to profit and much of it go overseas. Fewer staff would be employed and these would be less skilled.
In my view the efficiency argument is a furphy. The most efficient hospital I have worked in was an underfunded government hospital to a disenfranchised majority where staff were motivated. The most inefficient was a private system where profit was a significant factor. Efficiency is about organisation, involvement and motivation, not competition.
b. Failure to ensure a minimum level of universal access
Regulation:- Samuel reaffirms his reliance on regulation to ensure equity and access through his competitive purchaser. I have already addressed the difficulties in monitoring and preventing cherry picking, patient dumping and a number of other inequitable practices which have been rife in the competitive marketplace.
Samuel repeats his claim that we cannot afford universal services and that we will have to ration. Some will pay or insure for additional services. This may well arise. I have argued earlier that of all the options the corporate marketplace is least suited both for rationing and for providing a service which offers capitated basic care plus fee for service extras. The US experience indicates quite clearly that care will be rationed for profit in the former and that basic care will be drastically rationed while "extras" will be overserviced in the latter. These decisions are made in the board room.
Contrary to Samuel's claim health care in the USA is largely taxpayer funded through medicare and medicaid. Employer paid health insurance contributes significantly. A small number insure privately and many poorer citizens have no cover at all. Most of the funding is channeled through HMO's who function as purchasers - very similar to Samuel's model.
HERE -- for a more detailed
discussion of these arguments about equity.
Samuel targets free "pro Bono" work as the mark of altruism. This is a nonissue in countries with universal health coverage. It is vital in those without it. Its disappearance in the corporate market system in the USA has created a major social problem and intense anger at the insensitivity and inhumanity of the corporate groups. US citizens expect health care providers to embrace Samaritan values.
Altruism and a willingness to provide free care are essential in developing countries which simply do not have the funds to provide the sort of care their citizens need.
The talk of free care sidesteps the issue. Altruism is a part of our culture, both in the community and in health care. We admire it and identify with it. Health care more than any other objectifies it and allows the community to identify with it. When doctors fail the community feels betrayed. Marketplace culture delegitimises medical culture and creates intense paradigm conflicts. The consequences are revealed in the way doctors who became team players behaved in Tenet/NME, Columbia/HCA and in managed care when they acted as gate keepers.
Ron Williams described it as "--- a huge and depressing departure from the system as they (Australian readers) now know it."
HERE -- for a more detailed
discussion of Altruism
Samuel begs the major questions about research and teaching in a corporate system. The business community and large donors contribute significantly to research and government does not control this. If it did this money would disappear.
Corporations and wealthy businessmen, particularly those in the USA have supported research and education. They are likely to continue to do so. It is part of creating a corporate image and telling society who they think they are. Much of it has been genuinely altruistic. These people are members of society and altruism is one of our values. Research was not unduly restrained as it was not a legitimate area for market activity.
A more sinister thread has emerged in which research and teaching are seen to serve the market and the corporation. A culture is developing in which market paradigms pervade both and in which money is increasingly tied to corporate interests. This is what concerns researchers and teachers. In a technological age research has major plusses and negatives for corporations. They have an interest in benefiting from the pluses and minimising the negatives. The tobacco industry is a good example of how this is done. Humana and Tenet/NME both capitalised on the commercial opportunities.
It is the distortion of teaching and research by market thinking and market practices which is of concern. Once again there are major paradigm conflicts with norms and values which have been developed in research and education over long periods of time - at least since Socrates. It is the appropriateness of the market paradigm for research and educational contexts which is the issue.
A side issue is the plight of teaching hospitals in the marketplace. Their educational and research responsibilities render them uncompetitive. It is not a question of commitment.
CLICK HERE -- for a page about research and education which addresses these issues.
CLICK HERE -- to proceed to the next criticism - Number 20
CLICK HERE -- to go to the next section of Samuel's speech